Status of the Medicare Therapy Caps in 2012

Each calendar year the Medicare program imposes a caps or limits on the dollar amount of outpatient therapy services a Medicare beneficiary can get. This year the caps are $1,880, and, as always, are imposed on physical therapy (PT) and speech-language pathology (SLP) therapy combined, and separately on occupational therapy (OT) services. So, in effect, there are two distinct caps, both $1,880. (This is covered in detail on page 52 of Managing Your Medicare.) In addition, for several years legislation has been passed which allows for generous exceptions to these caps; basically, the therapist only has to certify that the therapy is medically necessary, and the cap, if reached, won’t apply.

Confusing to beneficiaries is that this exception process is enacted on a piecemeal basis, but legislation was passed so that the generous exception process will be in effect for all of 2012.

And remember that the cap applies to certain Part B services only, not to therapy you get as a hospital or skilled nursing facility Part A inpatient. Nor do they apply to home health agency (HHA) services, or to therapy you receive as an outpatient of a hospital. So if you are approaching the cap, you may wish to see if you can get equivalent services as the outpatient of a hospital, or, if you qualify for the homebound rule, from a home health agency.

Key Words: Physical Therapy Speech-Language Pathology Occupational Therapy Caps